and
the Reform of Medical
Education
Dr lR McWhinney
MD, FCFP, FRCP
Summary
Curriculum
Vitae
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l h e I r r i r er r r n r r f W c s t c r nO r r r a r i o
I-rnrkn, Onrario, Canrda
Reform of clinical education in
medicine is coming. Looking at
preuious cbanges in
medical
education, it is clear that tbey uere
driuen by (t) social cbanges and (2)
by major deuelopments in science and
tecbnologlt, Tbe leading role of Jenner
ancl Osler in the reform on present
systerns,is explained and tbe dynamic
changes in medical education at
Rockford Medical Scbool (Illinois)
Tbis is seen as a
bigblighted.
pioneering institution in our modern
tinxesand becauseJosepb Leuenstein is
an outstanding pioneer bimself, it was
a taell-matcbed. cboice to appoint
Josepb at Rockford, to lead. tbem fuftber
on in their reform. We bope to hear
mucb more about Rockford and its
leader in tbe years to corne.
S,Afr Fam Pract
1994115r297-300
KEYWORDS
Physicians,Family;
History of Medicine;
Education,Medical;
Education, Medical,
Undergraduate.
lntroduction
We are about to see the most radical
reform of clinical education since the
early years of this century. Changes in
medical education are driven by two
forces: social change and developments in scienceand technology. The
beginnings of our present system in the
English speakingworld are exemplified
by the careers of Edward Jenner and
William Osler.
In jenner's time, there were three ways
of entering the medical profession. A
small number attended university and
graduated with a classicaleducation
and a degree, but had very little clinical
sA FAr'rrLp
Yn n c r r c e 2 9 7
J U N E '9
19 4
experience in their training. Many
more were apprenticed to a surgeon or
physician and had a practical training;
and others were apprenticed to an
apothecary, who also provided a very
practical education. At the age of 12
in 1761,lenner was apprenticed to a
country
surgeon in Sudbury,
Gloucestershireand remained with him
lunttl 1770 when he went to London to
spend fwo years in London as a pupil
of |ohn Flunter, the eminent surgeon
and anatomist. Again, this training was
very practical, consisting, as it did, of
attending Flunter's patients at St
George's Hospital; but also it included
lectures in anatomy at l{unter's school
of anatomy, and anatomy at that time
included pathology.
In the first half of the l9th century) the
different branchesbecameconsolidated
into one medical profession. By the
ApothecariesAct of 1815, apothecaries
were allowed to practice medicine and
standards were set for their training. It
became customary for trainees to take
the double qualification of licentiate of
the Society of Apothecaries and
Membership of the Royal College of
Surgeons, thus becoming the
forerunners of the modern GP.
At the same time, the hospital was
becoming the base of medical
education. The new methods of
clinical examination introduced by the
French school of physician pathologists, and the verification of the results
by necropsy made the hospitals into
placeswhere the new clinical science
was advanced, and where medical
students were educated. William
Osler, born in Upper Canada in 1849,
entered the Toronto medical school in
1868. The medical course began with
two years in the dissecting room - the
student's only laboratory experience.
The clinical education was so unsatis-
factory at that time that Osler moved
to McGill in Montreal where medical
education was based on the Edinburgh
model. At McGill, the laboratory work
was no more advanced than in
Toronto, but at the Montreal General
Hospital, Osler found two valuable
assets:'much acute diseaseand a group
ofkeen teachers',even though the old
building was 'coccus and rat ridden'.
Specialisationamong the faculty was
unknown: all were general practitioners, practising both medicine and
surgery. Even so, McGill was the best
medical school in Canadaand probably
rivalled by only one American school,
Philadelphia.
American medical education in the
l9th century was indeed at a low ebb.
Any physician could open a medical
school and there were many such
places, where lectures were given by
poorly qualified teachers and clinical
teaching was minimal. Developments
in physics, chemistry, pathology and
bacteriology soon made reform a
necessity. The death knell of the
inferior proprietary schools was
sounded by the Flexner report of
1910. Flexner used /ohns Hopkins in
Baltimore as his model. founded in
IB70 on the lines of German medical
education.
Thus began the modern era. Medical
education became firmly based on the
laboratory sciences. Clinical education
was concentrated in teaching hospitals
which, as the 20th century progressed,
becameincreasinglyspecialisedand less
and lessrepresentativeof the burden of
illness in the general population. As
medicine became increasingly fragmented, generalpractitionerswere
excluded from medical schools, and
generalists of all kinds formed a
dwindling proportion of medical
faculties.
As medicine became
increasinglyf ragmented,
so GPs became more
and more excluded from
medical schools.
Most doctors graduating
today will probably
spend their professional
lives caring for patients
with chronic diseases;
unless.,.
To care for patients with
chronic illness,one must
have a long-term relationship with thern.
s A F A r { r L YP R A c r r c E 2 9 8
tulle tgg+
A number of factors have now
converged to make radical reform
necessary. Medical education always
goes to where the patients are, and
patients have begun to leave the
teaching hospital in large numbers.
The change in morbidiry pattern from
acute to chronic diseasemeans that
most sick people are at home and in
their community, not in hospital. If
they do attend hospital, they do so for
short term admissions or brief visits to
outpatients. Economic pressureshave
forced hospitals to cut beds, reduce
length of stay, and limit services to
thos-ewhich only hospitals can provide.
Advances in technology have reduced
the need for beds, for example in some
branches of surgery. IJnless there are
s o m e u n f o r e s e e a b l ed e v e l o p m e n t s ,
most doctors graduating today will
spend their professional lives caring for
patients with chronic diseasesof many
kinds. A large proportion of their
patients will be elderly, and more than
ever before will be in advanced old age.
To learn how to care for patients with
chronic illness, one must have a long
term relationship with them. An
understanding of context - family,
home, community - is crucial, and this
is what the teaching hospital cannot
provide. This is why medical education
must move closer to where people live,
in both the physical and metaphorical
sense.
Joseph Levenstein
Rockford, lllinois
and
In 1990, Joseph Levenstein left Cape
Town to become Professor of Family
and Community Medicine at the
University of Illinois at Rockford.
probably
represents
Rockford
tomorrow's medical school better than
any other in the world. It is the best
example I know of a community-based
medical school. To understand what
this means, it is important to
distinguish between medical schools
that are community-based and
community-oriented. A school can
claim to be community-oriented if it
shows awarenessof community health
problems and sendsits students out for
attachments to community practices
and institutions. But it can do all this
by remaining in the teaching hospital
or health science centre and looking at
the community through the window.
To be community-based requires a
redefinition of a medical school as an
organisation which uses the whole
health care system as an environment
of learning.
Rockville is a city of 150 000 people
about one hour's drive west of
Chicago. If one asked to see the
medical school, one would be directed
to a small building which houses the
administration and three basic science
departments. There is no teaching
hospital. All of the city's existing
hospitals are used for teaching.
Students complete one year of basic
science education before coming to
Rockford, after which they do six
months of pharmacology, pathology
and immunology. For the whole three
years of their clinical education,
students are based at one of the three
community health centres where they
care for a practice of 100 families
under the supervision of members of
the Department of Family Medicine.
Each student spends one and a half
days a week in the health centre) caring
for these patients and attending
coursesput on by the Department of
Family Medicine. For the remainder
of the week, they attend one of the
hospitals for their experience in the
specialities. The current position in
clinical education is therefore reversed.
Instead of being based in the hospital
and going out to the community,
Medical education must
move closer to where
peoplelive-ateaching
hospital does not provide
for this.
Rockville Medical School
has no single teaching
hospital.
The diagnosis is
primarily clinical as no investigations
have proved definitive.
s A F A f i r L YP R A c r r c E 2 9 9
J U N E1 9 9 4
clinical students are based in the
community and go out to the hospital.
The hospital still has an important part
to play in clinical education, but it is
no longer the main Part. As for the
tertiary care hospital, as time goes on it
tion. Rockford did well to choose
foseph Levenstein an outstanding
pioneer himself. TheY are well
matched. and I am sure we will be
hearing much more about the man and
the institution in the years to come.
We are about to see the
most radical reform of
clinical education in
medicine.
becomes less and less
appropriate for undergraduate education.
Its main role is likely to
be the postgraduate
training of specialists.
recentlY
Rockford
introduced a seven and
a half year programme
designed to train
students from rural
areas who will return
to these communities
as family doctors.
Fifteen students a year
(out of a class of fiftY)
are selected by a
committee representative of rural commuThe rural
nities.
the same
have
students
curriculum as the rest
of the class and in
elective periods return
to their rural community work there under
the supervision of a
local, family doctor.
After graduation, the
students enter the
school's family medicine residency programme. Again theY
have the same three
year experience as
other trainees, with an
additional six months
of rural training.
As a pioneering institution in medical educa-
ReducesPain.
IncreasesMobilitY.
O Conrenient
BD dosage
N'VollarwTS
TABLETS
i5 mg
sodium
Diclophennc
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